Heart failure Flashcards
What is heart failure?
HF is a clinical syndrome where the heart is unable to pump enough blood (cardiac output) to meet the metabolic needs of the body.
It is usually a result of structural or functional heart disease.
Symptoms/signs of left HF?
SOB on exertion
Orthopnoea
Paroxysmal nocturnal dyspnoea
Nocturnal cough (± pink frothy sputum
Reduced exercise tolerance
Fatigue
Tachycardia
Bibasal fine crackles on auscultation of the lungs
Cyanosis
Prolonged capillary refill time
Hypotension
Oedema Elevated jugular venous pressure
Pulsus alternans (alternating strong and weak pulse -less common)
S3 gallop rhythm (produced by large amounts of blood striking compliant left ventricle -less common)
Symptoms/signs of right HF?
Ankle swelling
Weight gain
Abdominal swelling and discomfort
Anorexia and nausea
Fatigue
Raised JVP
Pitting peripheral oedema (ankle to thighs to sacrum)
Tender smooth hepatomegaly
Ascites
Transudative pleural effusions (typically bilaterally)
What is New York Heart Association (NYHA) Classification of HF?
Assesses severity of symptoms.
Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitations or dyspnoea.
Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitations and/or dyspnoea.
Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary).
Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.
IVx of HF?
1st line = NT-pro-BNP level
2000ng/L (236pmol/L): refer urgently for specialist assessment and TTE <2 weeks.
400-2000ng/L (47-236pmol/L): refer for specialist assessment and TTE <6 weeks.
If <400ng/L: diagnosis of heart failure is less likely.
ECG
Transthoracic echocardiogram (TTE -assesses ejection fraction)
EF <40% = HF with reduced ejection fraction (HFrEF, systolic dysfunction).
EF >40% but with raised BNP = HF with preserved ejection fraction (HFpEF, diastolic dysfunction).
EF 50-70% with normal BNP = normal.
Bloods (deranged LFTs suggest hepatic congestion, hyponatraemia, hyperthyroidism, CVS RFs)
CXR -ABCDEF
What are the CXR finding in HF?
A: Alveolar oedema (with ‘batwing’ perihilar shadowing)
B: Kerley B lines (caused by interstitial oedema)
C: Cardiomegaly (cardiothoracic ratio >0.5)
D: upper lobe blood diversion
E: Pleural effusions (typically bilateral transudates)
F: Fluid in the horizontal fissure
Management of HF?
Weight loss if BMI >30.
Smoking cessation
Salt and fluid restriction - improves mortality
Supervised exercise-based group rehabilitation programme for people with heart failure.
Offer annual influenza and one-off pneumococcal vaccinations
Loop diuretics (e.g. furosemide or bumetanide) -for fluid overload
1st line: ACEi and BB
If symptoms persist and NYHA Class 3 or 4 consider adding:
Aldosterone antagonists -spironolactone or eplerenone.
Hydralazine and a nitrate for Afro-Caribbean patients.
Ivabradine if in sinus rhythm and impaired EF.
Digoxin = useful in those with AF. This worsens mortality but improves morbidity.
Cardiac resynchronisation therapy
Adverse effects of BB?
Bradycardia, hypotension, fatigue, dizziness
Adverse effects of ACEi?
Hyperkalaemia, renal impairment, dry cough, lightheadedness, fatigue, GI disturbances, angioedema
Adverse effects of spironolactone?
Hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/hair growth in women, changes in libido
Adverse effects of furosemide?
Hypotension, hyponatraemia/kalaemia
Adverse effects of hydralazine/nitrates?
Headache, palpitations, flushing
Adverse effects of digoxin?
Dizziness, blurred vision, GI disturbances
